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Medical Records

General Summary

A nonexempt position responsible for performing a variety of clerical duties to assist physicians, patients and clinical service managers.

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Duties and Responsibilities

  • Maintain Patient Medical Records in a confidential setting.
  • Retrieve and distribute medical records, loose notes and reports in accordance with established priorities and procedures.
  • Sort, file and collate a variety of medical records i.e. laboratory reports, clinic notes, etc in appropriate sequence and in accordance with established procedures.
  • File and retrieve medical records with established color-coded terminal digit filing system.
  • Research lost or missing records.
  • Sort records request according to priorities and provide routine information of a general nature such as record number, admission and discharge dates and record location to authorized requestors.
  • Generate new patient medical records as needed.
  • Data entry of medical records.
  • Purge files and separate according to needed material (make inactive file for old data).
  • Pick up and deliver patient medical records from clinics, hospitals or other designated facilities as scheduled or prescribed.
  • Review charts and make needed corrections.
  • Mail medical records as requested.
  • Assist with patient calls.
  • Confirm patient appointments if needed.
  • Maintain confidentially of all client/doctor related information.
  • Perform other related duties as assigned by the supervisor or doctors.

Qualifications

EDUCATION AND EXPERIENCE

Minimum requirements
  • High school diploma or General Equivalency Diploma (GED).
  • Must have a valid driver’s licenses and reliable transportation.
  • Must have COVID Vaccine.

Performance Requirements

     Knowledge
  • Knowledge of basic medical terminology and office procedures.
  • Knowledge of grammar, spelling and punctuation to type from draft, copy and review and edit reports and correspondence.
  • Knowledge of basic arithmetic to make calculations, balance and reconcile figures and make changes accurately.
  • Knowledge of computerized scheduling systems.
  • Knowledge of medical practice protocols related to scheduling appointments.
  • Knowledge of legal and ethical considerations related to patient information.
  • Knowledge of customer service principles and techniques.

    
Skills
  • Skill in operating office equipment.
  • Skill in using computer and medical records software.
  • Skills in organizational matters, including time management, prioritization, multitasking and problem solving.
  • Skill in putting information in preferred medical record system, meeting clinic standards.
  • Skill in dealing with masses of information in organized manner.
  • Skill in communicating effectively with physicians/clinicians about scheduling preferences.
  • Skill in generating reports from EMR as needed.
     Abilities
  • Ability to effectively communicate, read, understand and follow oral and written instructions.
  • Ability to establish and maintain effective working relationships with patients, physicians, other clinical staff and the public.
  • Ability to multitask effectively, dealing with phone calls, patients, staff and others calmly and pleasantly in all circumstances.
  • Ability to analyze situations and respond appropriately.
  • Ability to analyze medical records for completeness and accuracy, paying attention to detail.

Equipment Operated

Standard office equipment with emphasis on computer hardware and software including multi line telephone.

Work environment

Work performed in office environment. Involves frequent contact with staff, physicians and patients. May require some travel.

Mental/Physical Requirements

Mostly sedentary with some standing, walking and reaching. Daily and repetitive data entry utilizing ergonomic techniques. Periodic stress from handling high volume of calls, heavy workload and patient/physician requests.

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